Dural tears in spine surgery.

Dural tears are among the most commonly seen complications in spine surgery. Most studies in the literature indicate that long-term outcomes are not negatively affected, provided that the tears are diagnosed early and managed appropriately. Direct suture repair remains the preferred method for the management of durotomy caused by or found during surgery. However, recent literature reports encouraging results with sutureless repair. Understanding dural anatomy, dural healing, and cerebrospinal fluid dynamics is helpful in choosing among the available management options for dural tear.

Donor-site complications of autogenous nonvascularized fibula strut graft harvest for anterior cervical corpectomy and fusion surgery: experience with 163 consecutive cases.

BACKGROUND CONTEXT: The fibula is a source of bone graft for reconstruction of the appendicular and axial skeleton. PURPOSE: The aim of this study is to determine donor-site complications and morbidity in a large series of patients who underwent autogenous fibula harvesting for anterior cervical corpectomy and fusion (ACCF) surgery. STUDY DESIGN/SETTING: Retrospective review (Level III). PATIENT SAMPLE: One hundred sixty-three patients over an eight-year period who underwent ACCF with autogenous fibula. OUTCOME MEASURES: Donor site complications (such as infection, cellulitis, pain, damage to the superficial peroneal nerve, ankle instability, tibial stress fracture, and so forth), treatment, and final outcome were determined from patient records. METHODS: Retrospective study of patients who underwent ACCF with autogenous nonvascularized fibula strut graft over an eight-year period (from 1995 to 2002) was conducted. Donor site complications (such as infection, cellulitis, pain, damage to the superficial peroneal nerve, ankle instability, tibial stress fracture, and so forth), treatment, and final outcome were determined from patient records. RESULTS: One hundred sixty-three patients underwent ACCF with autogenous fibula graft during the study period. The most common short-term complication (lasting <3 months) was incisional pain, present in 86 of 163 patients (53%). Incisional pain lasted longer than 3 months in 25 of 163 patients (15%) but resolved in all but two patients by 24 months. Two patients (1.2%) developed superficial peroneal neuromas. Five patients (3%) developed tibial stress fractures. Two patients (1.2%) developed ankle instability. Fifteen (9%) patients developed cellulitis that resolved in all patients after a short course of oral antibiotics, with one additional patient developing a deep infection requiring surgical debridement and intravenous antibiotics. CONCLUSIONS: Although autogenous fibula is an excellent graft for multilevel ACCF reconstruction, surgeons should carefully consider the associated morbidity of fibular harvest before surgery. In this series, most complications were of short duration. However, nine patients with long-term complications required five additional surgical procedures. Therefore, patients who are scheduled to undergo autogenous fibula harvest should be advised about these potential complications.

Prevention, identification, and treatment of inadequate decompression of the cervical spine.

Inadequate decompression is one of the most common reasons for failed spinal surgery. Understanding the common areas where neural impingement occurs in the cervical spine, recognizing these changes on imaging studies, and recognizing the clinical manifestations help provide an intraoperative template for thorough decompression. A thorough preoperative workup assesses sagittal alignment of the cervical spine, determines if instability exists, identifies the location of the compression, and determines the etiology of the compressive lesion. This information guides the surgeon in deciding whether an anterior, a posterior, or a combined anterior and posterior approach will provide the most adequate decompression. It also will help determine whether arthrodesis is needed to provide optimal neurologic recovery. Patients who have had surgery and present with persistent neurologic symptoms, or who do not recover as expected, pose a unique challenge. The surgeon must determine if persistent compression exists, look for evidence of instability, and evaluate for irreversible spinal cord changes. Alternatively, other causes of neurologic changes, unrelated to neurologic impingement, must be ruled out. The initial step in achieving the goal of complete neurologic decompression is a thorough preoperative evaluation for static and dynamic causes of compression. The most important concept regarding inadequate decompression is to avoid it with careful preoperative planning of the index procedure.

Utilization of predonated autologous blood in anterior cervical corpectomy and fusion surgery.

OBJECTIVE: To determine the utilization of predonated autologous blood in patients treated with anterior cervical corpectomy and fusion (ACCF). METHODS: Retrospective chart review of 154 patients who underwent 1, 2, or 3-level ACCF over a 6-year period was performed. Variables collected included patterns of autologous and allogenic blood use, blood loss, and hematocrit at admission and discharge from the hospital. RESULTS: For 1-level ACCF, only 16.7% of the predonated autologous blood was used. As expected, use of predonated autologous blood increased with the number of corpectomy levels: Patients with 2 and 3-level ACCF used 29.0% and 53.4% of the predonated blood, respectively. The use of autologous blood significantly reduced the need for allogenic blood transfusion for 2 and 3-level ACCF. CONCLUSIONS: Autologous blood was used efficiently in 3-level ACCF, and predonation is associated with decreased allogeneic blood transfusion requirement in 2 and 3-level ACCF.

Quantifying the effect of the distal intrinsic release procedure on proximal interphalangeal joint flexion: a cadaveric study.

PURPOSE: The distal intrinsic release procedure is a popular treatment for intrinsic hand tightness. The literature remains ambiguous regarding the optimal amount of extensor hood to excise. Our goals were to quantify the mathematic relationship between the amount of extensor hood excised and proximal interphalangeal (PIP) joint flexion and to determine the minimum amount of extensor hood excision required to significantly change PIP joint flexion capability (the ability to achieve a change from the initial PIP joint angle). METHODS: We simulated the distal intrinsic release procedure by sequentially excising 5-mm strips (perpendicular to the long axis of the finger) of the extensor hood of cadaveric fingers beginning 5 mm proximal to the PIP joint center. We tensioned the intrinsic muscles to each digit to produce an intrinsically tight state and tensioned the flexor digitorum superficialis to produce an antagonist force and simulate the intrinsic tightness test. We measured PIP joint angle (the angle of the long axis of the middle phalanx relative to the proximal phalanx) in response to greater portions of excised extensor hood to quantify its contribution to intrinsic tightness. RESULTS: The relationship between the amount of extensor hood excised and the PIP joint flexion capability appeared quadratic, not linear. For the index, ring, and small fingers significant changes in PIP joint flexion were detected after resection of 59%, 26%, and 33%, respectively, of the extensor hood length. Although our results did not show statistical significance for the middle finger we project the critical amount to be at least 65%. CONCLUSIONS: We show PIP joint flexion changes after the distal intrinsic release procedure. We recommend excising a finger-dependent minimum amount of tissue before expecting a significant increase in PIP joint flexion capability.

Anatomic and radiographic analysis of arthroscopic tack placement into the anteroinferior glenoid.

Tack location within the anteroinferior aspect of the glenoid when performing simulated repairs of anteroinferior capsulolabral avulsions (Bankart lesions) was evaluated anatomically and radiographically. Arthroscopy was performed on six fresh-frozen cadaveric shoulders, and bioabsorbable tacks were placed through an accessory anteroinferior portal coming into the joint just above the subscapularis tendon using an outside-in technique. Tack location was studied after removal of all soft tissues. In addition to their position on the glenoid, the tacks were also evaluated for being partially or completely within bone. The tacks were recannulated with guide pins and anteroposterior, axillary, and en face glenoid radiographs of each specimen were obtained. This study provides quantitative data about the inferior placement limitations of the insertion angle and location of fixation devices within the anteroinferior glenoid through the anteroinferior accessory portal.